CARE HOMES FOR OLDER PEOPLE
Avondale Residential Care Home 45 Norton Road Stourbridge West Midlands DY8 2AH Lead Inspector
Christine Lancashire Unannounced Inspection 30th August 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Avondale Residential Care Home DS0000064415.V250759.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Avondale Residential Care Home DS0000064415.V250759.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Avondale Residential Care Home Address 45 Norton Road Stourbridge West Midlands DY8 2AH Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01384 442731 Stoneleigh Care Homes Ltd Kelly Bate Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Avondale Residential Care Home DS0000064415.V250759.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th February 2005 Brief Description of the Service: Avondale, which is on a main road near Stourbridge, is a fifteen bedded home accommodating older people. The home has been adapted and extended for purpose from a traditional property in its own grounds with mature gardens and car parking available. The facilities include 15 single bedrooms (10 with en-suite), two communal lounges, a dining area, one assisted bathroom, one shower and four communal toilets. A shaft lift is also available for access to the first floor. Staffing is available over a 24hr period (this includes waking night staff) with seventeen staff including a registered manager, care staff and a housekeeper, cook and handyman. The home is registered for personal care only. The home offers a homely environment in which personal care is provided to older people without other substantive needs outside of frailty that is a result of the ageing process. The current resident group is of mixed gender and all white European. The home has a clear policy on not offering emergency care. Avondale Residential Care Home DS0000064415.V250759.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, concentrating on key standards. The inspector spoke with the owner, manager, staff and residents, having longer discussion with two of the residents. The inspector also toured the building and examined records. What the service does well: What has improved since the last inspection? What they could do better:
The home will need to review its service and registration category in the light of the increased dependency of the prospective residents who are now being referred for care and the changing needs of present residents as they age. The owner is considering the future provision and has initiated discussion with the inspector on this subject. One personal issue was raised by a resident on the day of the inspection. This was brought to the attention of the manager, who agreed to discuss this further with the person concerned. Avondale Residential Care Home DS0000064415.V250759.R01.S.doc Version 5.0 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Avondale Residential Care Home DS0000064415.V250759.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Avondale Residential Care Home DS0000064415.V250759.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 Residents are provided with suitable information about the home. Their needs are assessed prior to admission to the home and they are assured that these will be met. EVIDENCE: The Statement of Purpose reflects the present conditions at the home. The needs of prospective residents are assessed prior to admission. Records were examined in relation to the last person admitted and these contained relevant details of their needs and how these would be met by the home. This home does not take emergency placements nor does it admit people with a high level of physical dependency. Avondale Residential Care Home DS0000064415.V250759.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Residents’ needs are set out in a plan, which is implemented by staff. Medication is stored and administered in an appropriate way, according to suitable policies and procedures. Residents are treated with respect. EVIDENCE: Each resident has an individual plan which is drawn up using information gained during the assessment process and added to when observations are made or when the resident or a relative provides further details. These plans cover various aspects of each resident’s life. They are prepared on the computer and so can be altered easily when circumstances change. The health needs of sampled residents were recorded in plans. Tissue viability and nutritional assessments are carried out at the time of admission. Details of visits from health professionals indicated that residents have appropriate access to a range of services. There are suitable arrangements for the storage and administration of medication. Records were up to date and complete. The medication system is overseen by a pharmacist who makes regular visits and whose reports were made available. Staff who administer medication are suitably trained. Residents confirmed that they are treated by respect. They have good access to the manager and owner and staff have time to spend talking with them.
Avondale Residential Care Home DS0000064415.V250759.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this visit. EVIDENCE: Avondale Residential Care Home DS0000064415.V250759.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this visit. EVIDENCE: Avondale Residential Care Home DS0000064415.V250759.R01.S.doc Version 5.0 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Residents live in a clean, safe, comfortable home, with sufficient facilities and their own possessions in their rooms. EVIDENCE: The building is clean and well maintained throughout. There are no unpleasant odours. There are two communal rooms, so residents can choose to sit in a quiet room. There are sufficient WCs and bathrooms which are kept clean. Sampled bedrooms were homely and one resident showed the inspector a comfortable room with many personal items, including a television and fish tank. The garden is accessible and has plenty of furniture. Residents enjoy sitting in the garden in the warmer weather. Since the new owners took over, alternative storage facilities have been identified for cleaning materials and other chemicals and these are suitable. The home does not have a sluice facility, but there is a suitable setting on the washing machine. The needs of the present residents are not such that a sluice is required, but this provision will need to be made, should the registration category change to include more dependent residents.
Avondale Residential Care Home DS0000064415.V250759.R01.S.doc Version 5.0 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The residents’ needs are met by sufficient staff who are suitably checked and trained and who receive a good level of support and supervision. EVIDENCE: Staff are recruited through a standard process and all appropriate checks are made. The records of the most recent recruit showed that references and a Criminal Records Bureau check had been obtained prior to appointment. Basic skills are covered during the induction period. There is a checklist for monitoring this period and an appraisal is carried out after a month. The rotas show a good level of staffing which exceeds the minimum level required. Rotas are drawn up on a six monthly basis, so that personal commitments can be taken into account. The manager prefers to use the services of regular staff to cover in times of staff shortage, but some use has been made of agency staff recently. There is a senior member of staff on each shift and the manager and deputy work alternate weekends. The deputy manager is responsible for coordinating training in the staff team. All staff receive induction training and in-house training is supplemented by outside trainers who lead the mandatory courses. First aid training has been provided this year and all staff have now completed this. Other mandatory courses are due to be renewed later in the year. All staff receive regular supervision and appraisal. A questionnaire is distributed prior to appraisals and this helps to keep the sessions focussed. There are regular staff meetings. In addition, the owner and manager are available for informal discussion on a daily basis.
Avondale Residential Care Home DS0000064415.V250759.R01.S.doc Version 5.0 Page 14 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this visit. EVIDENCE: Avondale Residential Care Home DS0000064415.V250759.R01.S.doc Version 5.0 Page 15 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Avondale Residential Care Home DS0000064415.V250759.R01.S.doc Version 5.0 Page 16 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard 1 Good Practice Recommendations The inspectors recommend that the owner reviews the provision in the light of the needs of people presently being referred to the home and the growing dependency needs of the present residents and makes an application to the Commission for Social Care Inspection for a variation in the home’s registration should any changes be made. Avondale Residential Care Home DS0000064415.V250759.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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